Non-pain Specialists Research Articles

An Algorithmic Overview of Advanced Pain Therapies: A Narrative Review.

Quickly referenceable, streamlined, algorithmic approaches for advanced pain management are lacking for patients, trainees, non-pain specialists, and interventional specialists. This manuscript aims to address this gap by proposing a comprehensive, evidence-based algorithm for managing neuropathic, nociceptive, and cancer-associated pain. Such an algorithm is crucial for pain medicine education, offering a structured approach for patient care refractory to conservative management. A comprehensive literary review with PubMed and regulatory documents from the United States Food and Drug Administration were searched for a variety of interventions. Pain syndromes were categorized into nociceptive and neuropathic pain, and an algorithm was constructed. Serving as an educational tool for patients, trainees, and non-pain specialists, and as an accessible reference for pain specialists, this algorithm bridges knowledge gaps, promotes interdisciplinary collaboration, and streamlines the learning curve for new practitioners. The strength of this algorithm lies in integrating extensive clinical data, emphasizing the latest clinical evidence, and providing a structured decision-making pathway.

Causes and management of acute oncological pain: a narrative review.

Acute pain in cancer is an important but often overlooked feature of many patients' oncological journey. Cancer-related pain is associated commonly with more persistent pain states caused by both the disease and its treatment, but there are numerous causes of acute pain which can develop in patients with cancer. This pain is frequently severe, can be challenging to manage and its suboptimal control can directly impact on oncological outcomes. This narrative review provides an overview of several causes of acute pain in patients with cancer and management approaches. A focused literature review was conducted to encompass the search terms 'acute pain', 'oncology' and 'cancer' in adult and paediatric populations. Acute pain is common in patients with cancer with a number of pain generators identified. Broadly, these are disease- and treatment-related but commonality in pain mechanisms and features are present. Importantly, these pain states do not occur in isolation; a patient may experience multiple acute pain episodes during their oncology journey. As the oncological treatment landscape shifts and increasing numbers of novel treatments are employed, the number of causes of acute pain in patients with cancer rises. This pain is often managed by non-pain specialists and suboptimal control has a variety of deleterious effects. It is important that awareness of acute pain in the oncological population is increased and treatment approaches, which adopt a biopsychosocial structure, are optimised.

Considerations on the Obstacles That Lead to Slow Recruitment in a Pain Management Clinical Trial: Experiences from the Belgian PELICAN (PrEgabalin Lidocaine Capsaicin Neuropathic Pain) Pragmatic Study.

A qualitative evaluation study of the prematurely terminated PrEgabalin Lidocaine Capsaicin Neuropathic Pain (PELICAN) study was performed. The PELICAN study aimed to examine pain management for localized neuropathic pain (LNP), as epidemiological figures have shown a high percentage of LNP patients in Belgium. The study compared systemic and topical medications according to pain relief, adverse effects, and several measures of quality of life. Achieving better study patient recruitment through qualitative research. To investigate and determine the causes of the observed recruitment problems in the PELICAN study, pain centers involved in the study as well as nonrecruiting pain centers were included. Furthermore, it aimed to highlight the positive and negative lessons learned from the conducted study and the number of obstacles the team had to overcome. A qualitative study, using a mixed methods approach, was performed. Multiple pain centers in Belgium completed an online survey, after which a structured interview was conducted to elaborate the responses in more detail. The broad topics of these meetings were feedback about the study, reviewing survey answers, and actions undertaken to enhance recruitment. Different factors contributed to the low recruitment rate in the PELICAN study, such as limited and late referral from the general practitioners to the Belgian pain centers, insufficient internal referrals from nonpain specialists, lack of specific expertise on LNP in some centers, scarcity of staff, limited reimbursement to administer complex analgesic schemes, overestimation of the patient population, and the reluctance of patients to participate in pain research. Additionally, shortcomings in the implemented study design and the need for more logistical investments were identified. The findings of the qualitative study demonstrate the need for further, more varied LNP research in Belgium, not limited to pharmacological studies. It also sheds important light on the recruitment obstacles that may be faced during these studies. Future studies could support this research by offering better proposals for feasibility and recruitment, for instance, by designing and conducting a compelling pilot study or applying social media during the recruitment phase. Clinical Trials. This trial is registered with NCT03348735. EUDRACT number 2018-003617-17.

Survey of physician comfort and attitudes on perioperative opioid prescription in patients with chronic pain

Objective: This study examines current practices, experiences, beliefs, concerns regarding negative outcomes and confidence of non-pain specialty anaesthetists regarding prescribing opioids to chronic pain patients. Design: An electronic cross-sectional survey was conducted by physicians from the Division of Anaesthesiology, excluding pain specialists, at the Singapore General Hospital. Methods: An online survey was conducted, investigating: (a) sociodemographic and practice characteristics; (b) current opioid prescribing practices; (c) experiences and beliefs towards prescribing opioid analgesics for chronic non-malignant pain; (d) confidence and comfort when prescribing opioids; and (e) educational and training needs in chronic pain management. Results: A total of 123 anaesthetists (80.9%) responded to the survey. It was noted that only 38.2% of respondents were comfortable managing patients with chronic pain. The majority (86.2%) felt that anaesthetists should be the primary doctors in the management of postoperative pain in chronic pain patients, and 61% believed that chronic pain trained specialist anaesthetists should be responsible; 92.7% of respondents agreed that patients who are educated about their pain tend to do better. Most importantly, 96.7% of respondents feel that they will benefit from more education regarding pain management in chronic pain patients. Conclusions: The majority of non-pain specialist anaesthetists recognise the importance of education regarding pain management for non-malignant chronic pain patients. Many feel that they are not confident in managing these patients and will benefit from continuing medical education and self-assessment courses to improve their confidence. These results could be used to enrich current pain management courses.

Safe Use of Opioids in Chronic Kidney Disease and Hemodialysis Patients: Tips and Tricks for Non-Pain Specialists.

In patients suffering from moderate-to-severe chronic kidney disease (CKD) or end-stage renal disease (ESRD), subjected to hemodialysis (HD), pain is very common, but often underestimated. Opioids are still the mainstay of severe chronic pain management; however, their prescription in CKD and HD patients is still significantly low and pain is often under-treated. Altered pharmacokinetics and the lack of clinical trials on the use of opioids in patients with renal impairment increase physicians’ concerns in this specific population. This narrative review focused on the correct and safe use of opioids in patients with CKD and HD. Morphine and codeine are not recommended, because the accumulation of their metabolites may cause neurotoxic symptoms. Oxycodone and hydromorphone can be safely used, but adequate dosage adjustments are required in CKD. In dialyzed patients, these opioids should be considered as second-line agents and patients should be carefully monitored. According to different studies, buprenorphine and fentanyl could be considered first-line opioids in the management of pain in CKD; however, fentanyl is not appropriate in patients undergoing HD. Tapentadol does not need dosage adjustment in mild-to-moderate renal impairment conditions; however, no data are available on its use in ESRD. Opioid-related side effects may be exacerbated by common comorbidities in CKD patients. Opioid-induced constipation can be managed with peripherally-acting-μ-opioid-receptor-antagonists (PAMORA). Unlike the other PAMORA, naldemedine does not require any dose adjustment in CKD and HD patients. Accurate pain diagnosis, opioid titration and tailoring are mandatory to minimize the risks and to improve the outcome of the analgesic therapy.

Pain Management in Patients with Multiple Myeloma: An Update.

Most patients with multiple myeloma (MM) suffer from chronic pain at every stage of the natural disease process. This review focuses on the most common causes of chronic pain in MM patients: (1) pain from myeloma bone disease (MBD); (2) chemotherapy-induced peripheral neuropathy as a possible consequence of proteasome inhibitor therapy (i.e., bortezomib-induced); (3) post-herpetic neuralgia as a possible complication of varicella zoster virus reactivation because of post-transplantation immunodepression; and (4) pain in cancer survivors, with increasing numbers due to the success of antiblastic treatments, which have significantly improved overall survival and quality of life. In this review, non-pain specialists will find an overview including a detailed description of physiopathological mechanisms underlying central sensitization and pain chronification in bone pain, the rationale for the correct use of analgesics and invasive techniques in different pain syndromes, and the most recent recommendations published on these topics. The ultimate target of this review was to underlie that different types of pain can be observed in MM patients, and highlight that only after an accurate pain assessment, clinical examination, and pain classification, can pain be safely and effectively addressed by selecting the right analgesic option for the right patient.

Something Must Be Wrong with the Implementation of Cancer-pain Treatment Guidelines. A Lesson from Referrals to a Pain Clinic.

ObjectiveThe World Health Organization’s (WHO) guidelines for cancer pain management were intentionally made simple in order to be widely implemented by all physicians treating cancer patients. Referrals to pain specialists are advised if pain does not improve within a short time. The present study examined whether or not a reasonable use of the WHO guideline was made by non-pain specialists prior to referral of patients with cancer-related pain to a pain clinic.MethodsCancer patients referred to a pain specialist completed several questionnaires including demographics, medical history, and cancer-related pain; the short-form McGill Pain Questionnaire (SF-MPQ); and the Short Form Health Survey SF-12. Data from referral letters and medical records were obtained. Treatments recommended by pain specialists were recorded and categorized as “unjustified” if they were within the WHO ladder framework, or “justified” if they included additional treatments.ResultsSeventy-three patients (44 women, 29 men) aged 55 years (range, 25–85) participated in the study. Their pain lasted for a mean of 6 (1–192) months. Mean pain intensity scores on a 0–10 numerical rating scale were 7 (2–10) at rest and 8 (3–10) upon movement. Most patients complied with their referring physician’s recommendations and consumed opioids. Adverse events were frequent. No significant correlation was found between the WHO analgesic medication step used and mean pain levels reported. There were 63 patient referrals (85%) categorized as “unjustified,” whereas only 11 patients (15%) required “justified” interventions.ConclusionsThese findings imply that analgesic treatment within the WHO framework was not reasonably utilized by non-pain specialists before referring patients to pain clinics.

Opioid-Induced Constipation Survey in Patients with Chronic Noncancer Pain.

Chronic pain patients relying on chronic opioid therapy are often challenged with opioid-induced constipation (OIC), a difficult condition to treat that has a significant psychosocial impact on those who are affected (Bruner et al., J Pain Res, 8, 2015, 289). Unlike other side effects of opioids, OIC does not resolve over time during chronic opioid use, and treatments used for functional constipation often fail to provide adequate symptom relief (Nelson and Camilleri, Therap Adv Gastroenterol, 8, 2015, 206). Estimates of the prevalence of OIC vary. It has been reported that 15% to 90% of opioid users are affected by OIC (Gaertner et al., J Clin Gastroenterol, 49, 2015, 9; Wan et al., Am Health Drug Benefits, 8, 2015, 93; Coyne et al., Clinicoecon Outcomes Res, 6, 2014, 269). In addition, a recent rise in opioid prescriptions by nonpain specialists has contributed to the increase in opioid-related side effects, such as OIC (Nelson and Camilleri, Therap Adv Gastroenterol, 8, 2015, 206; Tuteja et al., Neurogastroenterol Motil, 22, 2010, 424). We conducted a survey on OIC through PainPathways magazine in fall of 2014 and in spring of 2015. Survey results showed the prevalence of depression and the modification of opioid dosage were higher than previously thought. Additionally, we found that discussions with healthcare workers regarding OIC do not take place regularly. Our results re-emphasize the need for a consensus on OIC-specific diagnostic criteria, evidence-based treatment strategies, outcome metrics, and education about OIC for both prescribers and patients to improve clinical outcome as well as patient satisfaction.

Opioids for chronic pain: a knowledge assessment of nonpain specialty providers.

IntroductionAlthough the majority of opioids in the US are prescribed by nonpain specialists, these providers often report inadequate training in chronic pain management and opioid prescribing. The extent of health care providers’ knowledge of opioid prescribing for chronic pain has not been well established. The purpose of this study was to assess knowledge about the use of opioids for chronic pain among health care providers seeking pain-focused continuing medical education.Materials and methodsThe study participants (n=131) were recruited at a pain-focused continuing medical education conference for nonpain specialists. Upon commencement of the conference, the KnowPain-50 survey was completed. The survey comprised 50 questions, and 18 questions were related to opioid management. The focus of each opioid question was further categorized as either medicolegal (n=7) or clinical (n=11).ResultsThe majority of study participants were male physicians with a mean age of 51.8 years. The proportion of correct responses to the 50-item survey was 72%. The proportion of correct responses to the 32 nonopioid questions was 74%, and the proportion of correct responses to the 18 opioid questions was 69% (P<0.001). Similarly, the proportion of correct responses to the seven medicolegal opioid questions was 74%, and the proportion of correct responses to the eleven clinical opioid questions was 67% (P<0.001).ConclusionHealth care providers demonstrated gaps in knowledge about the use of opioids for chronic pain. Lower scores on clinically based opioid questions may indicate an opportunity to provide focused educational content about this area of practice. This information could be helpful in designing future educational modules for nonpain providers.

Pharmacological treatment of chronic non-cancer pain in pediatric patients.

Chronic pain in children and young adults occurs frequently and contributes to early disability as well as personal and familial distress. A biopsychosocial approach to evaluation and treatment is recommended. Within this approach, there is a role for pharmacologic intervention. A variety of medications are used for chronic pain conditions in pediatric patients. Medication classes include anticonvulsants, muscle relaxants, antidepressants, opioids, local anesthetics, and anti-inflammatory drugs. Data is sparse, and most medications are used without condition-specific approval by national regulatory agencies such as the Food and Drug Administration in the US and the European Medicines Agency. In the absence of evidence on which to base practice, optimal drug therapy decisions rest on understanding proposed mechanisms of pain conditions, extrapolation from adult data-when such exists, and empirical and experiential knowledge. Drug delivery systems have evolved, and practitioners have to decide amongst not only medication classes, but also routes of delivery. Opioids are not recommended for use by non-pain specialists for the treatment of pediatric chronic pain, and even then the issues are more complex than can be addressed here. This article reviews the major medications used for pediatric chronic pain conditions.

Post-surgical pain syndromes: a review for the non-pain specialist

This is a selective narrative review of the latest information about the epidemiology, impact, and prevention of chronic post-surgical pain (CPSP), intended primarily for those without a special interest in pain medicine. Chronic post-surgical pain is an important problem in terms of personal impact. It has staggering economic implications, exerts powerful negative effects on the quality of life of many of those it afflicts, and places a significant burden on chronic pain treatment services in general. It is well known that surgery at certain body sites is apt to cause CPSP, but emerging evidence shows a strong correlation between CPSP and demographic (young age, obesity, and female sex) and psychological characteristics (anxiety, depression, stress, and catastrophizing). Severe acute pain is a strong risk factor for CPSP, and this adds yet more weight to the argument that acute pain should be controlled effectively. In specific circumstances, CPSP can be reduced by regional anesthetic techniques, infiltration of local anesthetic, or preoperative use of gabapentin. The ability of other known interrupters of afferent nociceptive transmission-commonly used to reduce CPSP when administered at the time of surgery-is currently unproven, as is the hypothesis that the use of remifentanil during surgery worsens CPSP. Reduction of CPSP is a worthy long-term outcome for anesthesia providers to consider as they plan the perioperative care of their patients. More evidence is needed about the effect of currently used analgesics and other perioperative techniques on CPSP.

The Delayed Appearance of Neurological Signs in Intrathecal Granuloma Warrants Imaging Surveillance: A Case Series and Review of the Literature

Intrathecal pump therapy (ITP) has become a mainstay of treatment for the chronic, refractory nonmalignant pain patient. Increasingly, ITP therapy is being instituted for the failed back pain population. Inflammatory mass or granuloma is a complication that is considered "rare" or "uncommon." In this patient population, the symptoms of granuloma can often mimic the symptoms for which the patient is being treated. The case series reported here illustrates 4 cases of inflammatory mass. One patient presented with paralysis before she was diagnosed, and the remainder of the patients were asymptomatic at the time of diagnosis. The cases presented illustrate the need for broader education of inflammatory mass among nonpain specialists. Etiology, diagnosis and treatment guidelines of inflammatory mass are reviewed. The literature reviewed highlights the number of patients who present with paralysis as well as the need for regular screening of ITP patients.

Are We Lemmings Going Off a Cliff? The Case Against the “Interventional” Pain Medicine Label

There is a disturbing trend in pain medicine: the increasing tendency for pain practices to label themselves “interventional pain medicine.” My perspective is based on having practiced as a psychiatrist, an anesthesiologist, and for the last 15 years as a pain medicine specialist in both private and academic settings. For the last 8 years, I have been the chief of pain medicine at the University of Southern California. I see great cause for concern in the movement toward the “interventional subspecialty.” There is even a new subspecialty society, the American Society of Interventional Pain Physicians. The crux of the issue is that the interventional label implies that there is a distinction between “pain medicine” and “interventional pain medicine.” One possible reason that people have been making this distinction might be to prevent possible confusion with those physicians that only provide medications or other noninterventional treatments. Perhaps this confusion can be best avoided by using a term such as “comprehensive pain medicine.” The comprehensive pain physician will be understood to use expertise in medications, rehabilitation therapies, and interventional procedures. There are other, more concerning reasons for the trend toward using the “interventional pain medicine” label. As usual, money appears to be a key issue. Procedural medicine is more highly reimbursed than non-procedure treatments. There are many pain physicians and pain clinics that will only provide services for the more highly reimbursed treatments. These are not practices that seem to focus on the relief of pain and suffering, but rather seem to only focus on the financial bottom line. This kind of thinking will at best be short-lived as regulators crack down. But worse, as the overall reputation of our field diminishes, the opportunity will be left wide open for referring doctors to turn to radiologists to perform these seemingly “non-pain specialist” …

Cancer Pain Management.

Mayo Graduate School of Medicine, Rochester, Minnesota. obray.jon@mayo.eduCancer Pain Management. By Michael J. Fisch, M.D., and Allen W. Burton, M.D. New York, McGraw-Hill, 2006. Pages: 319. Price: $99.00.Symptomatic treatment is important to patients with cancer, where treatment of pain can become as high a priority for the patient as treatment of the cancer itself. Multiple specialists often contribute to the care of a cancer patient, and their investigations into clinical care can lead to a diverse literature with respect to symptomatic management. It is to this end that the authors have sought to introduce a text where the diverse experience of multiple specialists is collected into one resource dedicated to the relief of suffering secondary to cancer pain.Chapters are focused on specific topics relevant to the treatment of cancer pain, with appropriate supporting references. The target audience is oncology specialists, but the editors note the benefit of the text for nononcology physicians and allied health professionals. The chapters are organized with appropriate titles and subtitles. Numerous figures and tables contribute to a clear, effective presentation. I appreciated the inclusion of chapters such as ethics in cancer pain management as well as skin pain and wound management.The book’s sections include general principles of cancer pain management, management of specific cancer pain syndromes, special issues in cancer pain management, and interventional techniques and other specialized approaches. Appendices address practical clinical subjects. Some chapters are brief and somewhat underdeveloped for most specialists who are engaged in the care of cancer pain patients. But overall, each chapter is well referenced, and when brief, the reader is able to identify a resource for a more in-depth review of the subject.Basic pharmacology is addressed in the first section, with a succinct but useful review of opioids and other analgesics such as nonsteroidal antiinflammatory agents. Tables provide general medical dosing guidelines. Studies addressing cardiovascular morbidity and cyclooxygenase 2–specific inhibitors are presented as well. A dedicated chapter addressing prevention and treatment of opioid side effects is helpful given the frequency of unwanted symptoms with opioid therapy. A chapter dedicated to the basic neurobiology of cancer pain is also included.The section on management of specific cancer pain syndromes includes chapters dedicated to bone pain, neuropathic pain, and wound management. These chapters provide a blend of basic science and clinical information. They are succinct, but well referenced. The chapter dedicated to the management of wounds is clinically beneficial, because this is a common serious complaint for patients. Special issues in cancer pain management are addressed in eight chapters, including a diverse mix of subjects from ethics to complementary and alternative medicine in oncology. A chapter dedicated to pediatric palliative care is included in this section, covering a broad number of topics, from pain assessment to treatment, including pharmacology and interventional techniques.I would have liked more detail included in the interventional technique chapters, specifically dealing with neuraxial infusions and neurolytic nerve blockade. These chapters are best described as an overview of interventional treatment options for cancer patients. As someone who has not trained in radiation oncology, I found the chapter on palliative radiation therapy techniques helpful.After noting the complexity of developing healthcare guidelines in the absence of a mature clinical literature, the editors have included appendices describing guidelines used in cancer care at the M. D. Anderson Cancer Center. These appendices offer practical suggestions in how to approach the application of procedural pain techniques in cancer patients as well as methadone dosing.Overall, this textbook is a good orientation to cancer pain management, which will be valuable to medical students and residents as well as fellows starting advanced training in pain medicine. It will also serve well the nonpain specialist looking to increase knowledge of cancer pain management. For the mature pain specialist, much of the information presented will likely be a review. I will look forward to future editions, which will likely be of increasing value to practicing pain specialists.Mayo Graduate School of Medicine, Rochester, Minnesota. obray.jon@mayo.edu

Successful and Unsuccessful Outcomes with Long-Term Opioid Therapy: A Survey of Physicians' Opinions

The attitudes, beliefs, and experience of physicians will influence how they view the use of opioids for chronic nonterminal pain. To survey pain specialists and primary care providers (PCPs) to obtain their opinion and attitude on aberrant drug-taking behaviors. We surveyed three physician groups, mailing 250 surveys followed by two followups. The survey consisted of (1) questions about beliefs in the effectiveness of long-term opioid therapy and successful and unsuccessful outcomes and (2) a ratings section for possible indicators of unsuccessful long-term opioid treatment. In total 147 questionnaires (82 PCPs, 65 pain specialists) were returned. Pain specialists reported a greater number of patients undergoing long-term opioid therapy compared to nonpain specialists. Opinion regarding the effectiveness of long-term opioid therapy among all physicians was mixed but there was no significant difference between pain specialists and PCPs. There was agreement among physicians with regard to highly aberrant behaviors being indicators of failed long-term opioid therapy. The ratings of the following indicators showed differences between each group: no improvement in pain control, not being able to return to work, and a deterioration in relationships with others. Physicians reported increases or decreases in function to be the most important successful or unsuccessful outcome, respectively. This preliminary survey showed consensus among physicians that highly aberrant behaviors indicate a failure of chronic opioid therapy. However, when considering less egregious behaviors, it would appear a physician's experience and the number of patients they had taking opioids influenced their opinion.

Nerve Blocks in Palliative Care

It was a pleasure to review this book on nerve blocks in palliative care, written by two renowned specialists, Fiona Hicks, who is a consultant in palliative medicine at Leeds Teaching Hospitals Trust and Karen Simpson, a consultant in pain medicine within the same trust. Nerve Blocks in Palliative Care has been composed primarily for those who are not familiar with the full potential and risks of nerve blocks in patients with neoplastic disease. As such, the book is aimed primarily at those involved in the day-to-day specialist care of cancer patients such as palliative care doctors, oncologists and specialist nurses, as opposed to pain medicine anaesthetists. This is not a ‘cook book' as to how to perform the procedures, rather it is an excellent guide on how and when to refer a patient and as such should probably be compulsory reading for those who assess patients for referral to specialist pain teams. The book starts with a very general section on the philosophy behind the use of interventional blocks. I was amused by the paragraphs on team issues and communications. Many of the problems that are alluded to in these paragraphs are all too familiar to those of us who perform pain medicine interventions. Reading this book prior to referral would help prevent some of the many misunderstandings that pain specialists come across in our practice of pain medicine. The miracle pain relieving injection with no risks does not exist! Similarly, there is no such thing as a ‘simple injection'. Team members can disagree on what is the best way of managing a particular problem and they need to be involved in discussions, in addition to the patient and the relatives. There is also a very good chapter on the assessment of pain, which is something that is often poorly performed by the nonpain specialist when you take into account the multiple pain mechanisms that may be present at any one time. There now is a wealth of information about the aetiologies and underlying mechanisms of pain in cancer patients and to try and summarise this in a chapter was obviously difficult. The chapter on pain syndromes covers this area well for the nonpain specialist. The central part of the book then proceeds to cover individual invasive procedures, ranging from trigger point injections through to the more complex neurolytic blocks and intrathecal infusions. These chapters have involved a significant amount of thought and work. Each technique is introduced by comments on specific indications and contraindications; it could be argued that these are the most important points for a non-specialist in pain medicine to take on board. Understanding the limits of any procedure and the complications that may occur are also vital. The limits and complications need to be discussed by a sympathetic person prior to referral to a pain specialist, as the patient needs to be prepared to participate in a discussion with the pain specialist in greater depth. Currently, it is not uncommon for the pain specialist to have to break the news that severe complications can occur and that there is a failure rate; the myth of the ‘miracle risk free injection' is broken, which may result in profound disappointment and occasionally increased patient distress. Finally, the book finishes with a chapter, albeit brief, on the ethics involved in pain medicine and the terminally ill. Once more, we are urged to consider not only the potential benefits but also the risks. At the end of the day, those performing the procedures are best suited to tackle the issues around interventions for pain management. However, it is important that the potential for improved pain relief and reduced suffering are not missed by those involved in the day-to-day management of cancer patients. Also, patients need to have an understanding of what may be involved prior to meeting the pain team. Recently, I have been asked to give a talk on invasive procedures to our palliative care team. I have responded by asking that they read this book on nerve blocks in palliative care – I feel that would provide them with more education than I could provide in an hour. My talk will be around this excellent book!

Targeting pain education for the non-pain specialists: Where should efforts be directed?

In the last decades, significant efforts have been made in improving the delivery of pain care. Improving pain management for our patients requires more than just increasing the availability of pain specialists and pain clinics. In the hospital setting, the nursing staffs spend more time with patients, and often times serve as the link between patients and physicians for pain care. The aim of this study was to define the specific areas of pain knowledge and attitudinal deficits in such providers for specific goal directed quality improvement activities.

Prediction of outcome: Physicians opinions on chronic opioid therapy

Current controversies with chronic opioid therapy may rest on the varying definition of successful and unsuccessful outcomes of opioid treatment among individual physicians. The purpose of this study is to develop descriptors for successful and unsuccessful outcomes with chronic opioid therapy. Three physician groups (pain specialists, primary care providers at a local community hospital, and a large teaching hospital) were surveyed by mail. The survey consisted of two parts: 1) questions about their belief in the effectiveness of chronic opioid therapy and open-ended questions relating to successful and unsuccessful outcomes, 2) a ratings section for possible indicators of unsuccessful chronic opioid treatment. An initial mailing of 250 questionnaires resulted in a response rate of 38%: pain specialists (67%) and non-pain specialists (33%). Pain specialists reported a greater number of patients on chronic opioid therapy compared with non-pain specialists (median 50 vs 5). Opinion regarding the effectiveness of chronic opioid therapy among all physicians was mixed (13% not effective, 44% unsure, 45% effective) and was not correlated with specialty or the number of patients physicians had on opioids. On the open-ended questions, good pain control (72%) and increased functionality (72%) were reported to be the most common successful outcomes. Poor pain control (51%), decreased functionality (43%), dose escalation (40%) and adverse effects (26%) were the most often reported unsuccessful outcomes. The ratings of the following descriptors varied: single loss of prescription; states preference for route of administration; patient reports an addiction problem; multiple stated allergies or adverse effects to non-opioid therapies; single ER visits; and recent suicide attempt. Although some disagreements exist among physicians as to what behaviors can be classified as aberrant, the majority of physicians consider improved functionality an equally important outcome as pain reduction, and a measure of the success of chronic opioid therapy. Current controversies with chronic opioid therapy may rest on the varying definition of successful and unsuccessful outcomes of opioid treatment among individual physicians. The purpose of this study is to develop descriptors for successful and unsuccessful outcomes with chronic opioid therapy. Three physician groups (pain specialists, primary care providers at a local community hospital, and a large teaching hospital) were surveyed by mail. The survey consisted of two parts: 1) questions about their belief in the effectiveness of chronic opioid therapy and open-ended questions relating to successful and unsuccessful outcomes, 2) a ratings section for possible indicators of unsuccessful chronic opioid treatment. An initial mailing of 250 questionnaires resulted in a response rate of 38%: pain specialists (67%) and non-pain specialists (33%). Pain specialists reported a greater number of patients on chronic opioid therapy compared with non-pain specialists (median 50 vs 5). Opinion regarding the effectiveness of chronic opioid therapy among all physicians was mixed (13% not effective, 44% unsure, 45% effective) and was not correlated with specialty or the number of patients physicians had on opioids. On the open-ended questions, good pain control (72%) and increased functionality (72%) were reported to be the most common successful outcomes. Poor pain control (51%), decreased functionality (43%), dose escalation (40%) and adverse effects (26%) were the most often reported unsuccessful outcomes. The ratings of the following descriptors varied: single loss of prescription; states preference for route of administration; patient reports an addiction problem; multiple stated allergies or adverse effects to non-opioid therapies; single ER visits; and recent suicide attempt. Although some disagreements exist among physicians as to what behaviors can be classified as aberrant, the majority of physicians consider improved functionality an equally important outcome as pain reduction, and a measure of the success of chronic opioid therapy.

Clinician Beliefs About Opioid Use and Barriers in Chronic Nonmalignant Pain

A survey of the medical directors of multidisciplinary pain clinics and multidisciplinary pain centers listed in the American Pain Society Pain Facilities Directory was conducted to define those pain specialists' beliefs about the role of opioid analgesia in 14 types of chronic nonmalignant pain. Respondents also reported their perceptions of barriers to their prescribing opioids for chronic nonmalignant pain and what they perceived as barriers to opioid prescribing for chronic nonmalignant pain by other, non-pain specialist clinicians in their communities. The respondents are characterized by demographics, disciplines, specialties, and time in practice. The percentage of time that a pharmacist was available in the pain programs also is reported. There is increasing acceptance of opioids for most of the listed types of chronic nonmalignant pain, but the acceptance varies by types of pain syndromes. Opioids were most consistently accepted for sickle cell disease pain and least commonly endorsed for headaches, myofascial pain, and fibromyalgia. Factors that may influence clinicians' perceptions about opioids are discussed.

Pain Management for the Practicing Physician

Associate Professor of Anesthesia; Harvard Medical School; Chief, Division of Pain Medicine; Beth Israel Deaconess Medical Center; Boston, MassachusettsPain Management for the Practicing Physician. Edited by Gordon A. Irving and Mark S. Wallace. New York, Churchill Livingstone, 1997. Pages: 330. Price:$49.95.When I started my career in pain medicine 20 yr ago, there was scarcely a chapter about the topic, let alone a textbook. Today, with the rapid growth of interest in the field of pain medicine, the practitioner is faced with an often difficult choice of pain texts.Pain Management for the Practicing Physician provides a succinct but comprehensive collection of information regarding the treatment of painful syndromes. The text starts with a very useful glossary of pain terminology. Section 1 includes four chapters about the anatomy, physiology, and pharmacology of pain. Section 2 provides a “cook-book” reference about how to treat 23 painful syndromes, including headaches, herpes zoster, lower back pain, pediatric pain, reflex sympathetic dystrophy, and spasticity. Algorithms are presented for each diagnosis in a chart format, with step-by-step instructions about how to proceed in treating each condition. Recommendations proceed from plan A to plan B to plan C, and so on, and end with “referral to pain specialist.” The text then offers numerous approaches that the pain specialist might use during such a referral. Also included are pertinent case studies to clarify the use of the algorithms.Although section 2 provides the major bulk of the text, section 3 offers a review of the psychologic aspects of pain management, including a very useful chapter with algorithms about opioid detoxification.Section 4 discusses acupuncture, physical therapy, and transcutaneous electrical nerve stimulation, and section 5 consists of a chapter regarding the future of pain medicine.I do have a few criticisms. Although the “Reflex Sympathetic Dystrophy” chapter states that a sympathetic block is routine in the diagnosis of reflex sympathetic dystrophy, it completely leaves blocks out of the algorithm, suggesting use of a number of pharmacologic manipulations and even acupuncture and coping skills before neural blockade. I also thought the acupuncture chapter to be rather meager.Although the authors clearly state that this text is intended to provide non-pain specialists with guidelines for pain treatment and for referral to a pain specialist, I believe this text would be an excellent resource for those training in a pain fellowship program and also for anesthesia residents during their pain rotation. The cost of $50 is what I would consider to be quite reasonable for a text for such purposes.Carol A. Warfield, M.D.Associate Professor of Anesthesia; Harvard Medical School; Chief, Division of Pain Medicine; Beth Israel Deaconess Medical Center; Boston, Massachusetts